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Proactive Recovery with Care Management

Providing care for a loved one can be stressful at any stage, but stress tends to increase after being discharged from the hospital when the focus needs to be on a safe recovery. After an event such as a fall or surgery, it is critical for your loved one to recover in a safe environment to reduce the risk of rehospitalization. Readmissions can be initiated by a lack of post-discharge planning, insufficient follow up, medication related issues, and falls. These examples can take place during recovery and be detrimental to the health of your loved one if a proper recovery plan is not put in place.

Statistics have shown that 40% of fall injuries will not discharge to their home, but will get directed to long term care. Moving to an assisted living community is a popular option, but if you or your loved one is not ready for the community move there is an alternative option; home care. Home Care allows your loved one to remain in the comfort of their home and focus on recovery with a Care Team that comes directly to them. In-home care teams aid in reducing readmission by utilizing Care Management as a proactive care tool.

Home Care Partners relieve post-discharge stress and improve the quality and speed of recovery with our Care Management Team. Care Management is a collaborative approach to managing conditions and injuries that pose a risk of rehospitalization. This means that if your loved one suffers an injury or has surgery, our Care Team will communicate with their doctors and physical therapists to provide a holistic recovery. Collaborating with all of your loved one’s health professionals allows us to fully understand their health status, be aware of challenges that need to be monitored, and create a care plan to prioritize recovery. Our care team prioritizes recovery through providing medication reminders to reduce medication errors, attending follow-up appointments to fully communicate your loved one’s health status and update you on any changes made by the physician, utilizing medical equipment, and recognizing when home safety equipment is needed to create a safer environment. Additionally, the team is experienced with physical therapy exercises from hands-on training provided by a therapist to promote strength and balance. All of these skills contribute to proactive care and result in a reduced risk of rehospitalization as our caregivers are creating a safe environment and identifying potential problems before they occur through collaboration and on-going communication.

Home Care Partners’ utilization of Care Management is unique and approaches management differently than other home care agencies. Our team charts electronic care notes and documentation with the details of every visit with your loved one. Using electronic care notes enables us to receive real-time updates on your loved one’s health changes and gives us the ability to provide proactive healthcare. Proactive care allows our care team to pinpoint any challenges and work with the interdisciplinary care team to manage chronic conditions and identify current health changes or concerns. If we see a concern, we can work with you to determine if your loved one should be admitted into the hospital or if we can connect a provider to assess and provide care in their home. We are able to help anticipate this need earlier and prevent a larger health decline. If your agency is utilizing paper charts the information that they have available is not real-time and there is little to no accountability as the documentation is not read in a timely manner. Because of this, there is no way to know if your loved one's condition is being monitored often or at all.

By choosing a Home Care provider that utilizes proactive and real-time Care Management, you know that your loved one isn’t just receiving help with their daily care, but receiving oversight and monitoring for all of their health conditions with access to communicate with all of their other healthcare providers. To start care for a loved one that is about to be or is currently discharged, reach out to us at 402-780-1211 or visit Contact Us for more ways to connect.

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